FORM E

[Sec Rule 5 (1) ]

Notice under Section 6 of the Maternity Benefit Act, 1961.
(Name of Establishment).
I,

(Name of woman) wife/daughter of

employed as

at

(Name of establishment), hereby

give notice that I expect to be confined within six weeks next following from the date
of this notice/ have given birth to a child on
(date) and shall be absent from work from

(date) I shall not work in

any establishment during the period for which I receive maternity benefit.
2. For the purpose of Section 7, I hereby nominate

(here enter name and

address of the nominee) to receive maternity benefit and/or any other amount due to me
under the
Act in case of my death.
Signature of an Attester in case the woman is
not able to sign and attires thumb impression.
Dated..

Signature or thumb impression of

woman.

FORM F
[See Rule 5 (3) ]
Form of receipt of Maternity Benefit
(Name of establishments).
The undersigned, a woman*employee/the nominee of
Woman employee/legal representative of
Woman employee deceased in
Establishment) at
and/or other

in

(name of

District received maternity benefit

amount due under the Maternity Benefit Act, 1961, from the employer of the establishment
referred to above, as detailed below:Rs.
Rs.
Rs.
Rs.

being the first installment of maternity benefit paid on..

being the Second installment of maternity benefit after..
delivery paid on
being the medical bonus under Section 8 of the Act paid on..
being the wages for the leave period from..to..mentioned

Under Sec. 9 or 10.

*My/Her confinement/miscarriage took place on
or I/She fell ill because
of pregnancy, delivery, premature birth of child a miscarriage on .. in consequence
I
her nominee/legal representative have received that aforesaid amounts prescribed
in Section 5,8,9 and 10 of the Maternity Benefit Act, 1961.
Signature or thumb impression
of *Women employee or her
nominee or legal representative,
Signature of an attester in case the
woman is not able to sign and
affixes thumb impression.
Date
Strike out unnecessary portion.

FORM B

[See Rule 4 (1)]

This is to certify that I examined

wife/daughter of

a woman employee in

(name of establishment on

(date) and found/ cannot discover that she is pregnant and is expected to be delivered of a child
within (month and/days) from the above mentioned date/has undergone miscarriage/has been
delivered of a child on

(date) or is suffering from

(date) from illness arising out of pregnancy/

delivery/premature birth of child or miscarriage.

Date.

Signature, qualifications and designation of Medical

Officer/Registered Medical Practitioner.

Definitions of child and miscarriage as in the Maternity Benefit Act, 1961.

1. Child includes a still-born child.
2. Miscarriage means expulsion of the contents of a pregnant uterus at any period prior to or
during the twenty sixth week of pregnancy but does not include any miscarriage , the
censing of which is punishable under the Indian Penal Code.

FORM D

[See Rule 4 (4) ]

This is to certify that I examined
a woman employed in

wife/daughter of
(name of establishment) and found that she has been

delivered of child/has undergone miscarriage on

Date

(date).
Signature of Registered mid-wife.

Definitions of child and miscarriage as in the Maternity Benefit Act, 1961.

1. Child includes a still-born child.
2. Miscarriage means expulsion of the contents of a pregnant uterus at any period prior to
or during the twenty-sixth week of pregnancy but does not include any miscarriage, the
causing of which is punishable under the Indian Penal Code.

Resignation

Resignation:- (1) A member of the Board, not being an ex-officio member may resign his
office by a letter in writing addressed to the Chief Commissioner.
(2) The officer of the member of the Board, shall fall vacant from the date on which his
resignation is accepted by the Chief Commissioner, on the expiry of thirty days from the date of
receipt of intimation of the resignation whichever is earlier.